Healthcare Provider Details

I. General information

NPI: 1104437631
Provider Name (Legal Business Name): TARA LEE NIMTZ
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/10/2020
Last Update Date: 02/12/2024
Certification Date: 02/12/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

400 TEEGARDEN ST
LA PORTE IN
46350-3175
US

IV. Provider business mailing address

400 TEEGARDEN ST
LA PORTE IN
46350-3175
US

V. Phone/Fax

Practice location:
  • Phone: 219-326-0043
  • Fax: 219-326-8909
Mailing address:
  • Phone: 219-326-0043
  • Fax: 219-326-8909

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163WE0003X
TaxonomyEmergency Registered Nurse
License Number28155899A
License Number StateIN
# 2
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number71010414A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: